Is it PCOS or FHA?
Is it PCOS or FHA?
Understanding the cause of secondary amenorrhoea (when menstruation stops after it is established) is both challenging and essential. Two common causes—Polycystic Ovary Syndrome (PCOS) and Functional Hypothalamic Amenorrhoea (FHA)—often have overlapping signs and symptoms but require very different management approaches. Correct diagnosis is crucial for effective treatment.
This blog explores how to better differentiate these conditions, drawing on insights from my comprehensive evaluation of the NHS England policy for secondary amenorrhoea assessment. For my fully-referenced research paper “Evaluation of an NHS England Policy for Secondary Amenorrhoea Assessment and Differential Diagnosis” click here to download. For a concise version, read on.
Introduction
In my clinical experience, I’m frustrated and saddened by the number of clients I see whose amenorrhoea is misdiagnosed or not fully explained, leaving them in the dark with no tools to bring their bodies back into balance. So much so, that I made this a focus of my research for my MSc in clinical nutrition.
Secondary amenorrhoea affects approximately 3-5% of women of reproductive age, with as much as 60% estimated in athletes. The two leading causes, PCOS and FHA, differ significantly in their pathophysiology, but can present similarly. Accurate diagnosis is vital since the typical management strategies for PCOS and FHA are so different. This blog aims to help you understand these differences and overlaps and is based on my clinical experience and academic research.
It is my hope you can use this knowledge with a qualified team of healthcare professionals to give you the best chance of an accurate diagnosis and effective treatment plan.
Understanding PCOS
PCOS is a multifaceted hormone disorder often associated with metabolic abnormalities. It is characterised by chronic anovulation (lack of ovulation), hyperandrogenism (e.g. high testosterone) and polycystic ovaries. Symptoms often include irregular menstrual cycles, excessive body hair, and acne, linked to elevated androgens (male sex hormones). The Rotterdam criteria are commonly used for diagnosis, which require two of the following three features:
Oligo- or anovulation (irregular, infrequent or no ovulation)
Clinical and/or biochemical signs of hyperandrogenism
Polycystic ovaries seen on ultrasound
Management for PCOS typically involves lifestyle modifications like weight loss and a low-calorie diet, especially in overweight individuals, and modified carbohydrate intake. Medications such as hormonal contraceptives and insulin-sensitising agents may also be prescribed.
Understanding Functional Hypothalamic Amenorrhoea
FHA is primarily caused by significant stress, weight loss, low energy availability, and excessive exercise, suppressing the hypothalamic-pituitary-ovarian axis. This results in low oestrogen levels, missing or infrequent periods, long-term bone density issues and an increased risk of cardiovascular and other complications. Diagnosis often involves ruling out other causes of amenorrhoea and assessing lifestyle factors.
Management of FHA typically focuses on reversing any underlying energy deficit, nutritional rehabilitation, stress reduction, and sometimes reduced physical activity.
The Diagnostic Challenge
Despite their different causes, PCOS and FHA can present with similar symptoms, such as irregular or absent menstrual cycles and polycystic ovaries on ultrasound. This overlap can lead to diagnostic confusion.
The National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summary (CKS) aims to provide clear guidance to general practitioners (GPs) and other primary healthcare professionals (HCPs) for accurate diagnosis and management of amenorrhoea. However, my research (conducted in 2023) showed that the evidence underpinning the CKS recommendations is moderately poor, requiring updates to align with recent clinical guidelines. For instance, for a more accurate PCOS diagnosis, the criteria for identifying ovaries as polycystic should be revised based on newer studies suggesting higher follicle thresholds (more than 20-25 follicles on either ovary and/or an ovarian volume ≥10ml). Newer technology should be used where possible and transvaginal ultrasound is preferred for PCOS diagnosis.
Comparative Criteria
This table provides a quick comparison between PCOS and FHA, helping to distinguish between these two common causes of secondary amenorrhoea. It is based on the typical clinical presentation of each condition and my evidence review.
I want to stress that patients should be evaluated in much more detail than with a simple checklist as there are nuances within these criteria that must be considered.
Criteria in more depth
Here, I expand on certain criteria for each condition, how they overlap and why more in-depth investigation is often needed for an accurate diagnosis.
Ultrasound Criteria
If a patient has missing periods and the appearance of polycystic ovaries on ultrasound (PCOM), it might suggest PCOS (Polycystic Ovary Syndrome) based on the Rotterdam criteria. However, this issue remains controversial since these criteria are easily met by someone with FHA, with PCOM reported in as many as 50% of cases.
In the absence of regular ovulation, both conditions can be associated with an increased number of visible developing follicles (termed “cysts”). So, it is important to consider other symptoms and the overall context.
Hormonal Profiles
Since both FHA and PCOS can occur with ‘normal’ hormone levels, their differentiation is reliant on a careful examination of the overall hormone pattern. The use of wider panels examining a greater array of hormones and other laboratory markers can be helpful.
For example, the inclusion of free triiodothyronine (T3) may guide the identification of FHA in cases of energy-deficiency-related menstrual dysfunction. Free testosterone, as opposed to ‘total testosterone’, is now considered the optimal marker to detect biochemical hyperandrogenism (followed in no specific order by total testosterone, DHEA-S, androstenedione).
It is also worth bearing in mind that the adrenal glands (a major source of stress hormones) are also a major source of androgens in women. In PCOS specifically, higher levels of androgens can be linked to increases in LH, which is thought to play a role in the "over-secretion" of adrenal androgens. Other causes of a higher androgen load may start in the ovary itself or result from a loss of insulin sensitivity or inflammation.
Finally, whilst PCOS and FHA cannot technically co-occur (at the same time), it is possible for a patient to experience both conditions. Since FHA results in the suppression of the reproductive axis in women, it will always mask PCOS, which is essentially the loss of normal hormonal communication (or "synchronicity"). Hormonal shifts can also occur when recovering from FHA and may be temporary in nature. Addressing factors that disrupt the normal functioning of the hormone-axis, at all stages of the patient’s journey, is key.
Detailed hormone and other laboratory assessments can aid in differentiation of PCOS and FHA, and guide practitioners as to the most appropriate care and recovery approach – at all stages of the patient’s journey.
Lifestyle, Physical Activity and Other Symptoms
A thorough evaluation of the patient's lifestyle, including their nutrition and exercise, is crucial. FHA is often linked to significant lifestyle changes that result in energy deficiency, whereas PCOS might be more associated with metabolic issues like insulin resistance.
Secondary symptoms such as hair loss and high levels of stress or anxiety can occur in both conditions. Their presence alone, alongside missing periods, is not diagnostic.
If your medical provider does not take a detailed health history including the above, they may miss some important details to help with a diagnosis.
Weight and Body Composition:
Current clinical guidelines still recommend body mass index (BMI) is calculated to identify weight-related causes of amenorrhoea, noting that a higher BMI may suggest PCOS, whilst a low BMI may suggest an eating disorder or relative energy deficiency in sport (linked to FHA).
Whilst this guidance is well-evidenced, my research emphasises that (without nuance), this binary distinction is oversimplistic and potentially misleading. Although PCOS patients are more likely to be overweight than women without the condition, PCOS can occur at any weight, including in those with a normal or even low BMI.
Similarly, whilst a high BMI is less common in FHA, having a normal or ‘ideal’ body weight is well-documented in the published literature, and weight loss (regardless of BMI) may be more important. Investigating the cause of recent weight changes and energy balance is essential.
What you can do
I believe that empowering patients to understand their condition and actively participate in their care is crucial for better outcomes. Here are some things I recommend you can do if you are worried about getting an accurate diagnosis.
Seek Specialist Advice
Given the complexity of these conditions, consulting with both an endocrinologist and gynaecologist who specialise in reproductive health can provide a more accurate diagnosis and treatment. They should do a thorough investigation including a full health history, lifestyle assessment, specialised blood tests, and sometimes imaging.
Working with a registered nutritionist who specialises in hormonal health can give you personalised support for the food and lifestyle changes you can make to help with your condition and symptoms. In my clinic, I also provide additional lab tests not always covered by the NHS (such as those mentioned above and below).
Communicate Openly
Open and honest communication with healthcare providers about symptoms, lifestyle, and concerns can lead to more accurate diagnosis and effective management. Don’t be shy about asking questions if you want more information.
Get the right lab tests
Lab tests to measure hormones and other biochemical markers are essential for a thorough investigation. Below are some examples of tests that health professionals might recommend. Work closely with your medical team to determine which tests are necessary for accurate interpretation and diagnosis.
NHS and private medical doctors and some other health practitioners can order specialised blood tests that will measure many different markers and may include:
LH and FSH
Oestradiol
Androgen profile (including testosterone, DHEAS, SHBG and FAI)
HbA1c and fasting insulin
Thyroid function
Prolactin (to check for other potential causes of missed periods)
AMH (depending on the need to rule out conditions like premature ovarian failure or menopause)
In addition to the above, in my private clinic, I also recommend the inclusion of certain vitamins, nutrients and other markers to gather all the insights we need before working together.
Some registered nutritionists and functional medical practitioners can order other lab tests, not available on the NHS, if you want additional information about your health. You can read more about some of the tests I use with my clients to get a more detailed picture of what may be driving symptoms, here.
Among these tests, I offer a dried urinary analysis of comprehensive hormones (DUTCH test). This convenient at-home urine test provides a comprehensive sex hormone profile, useful in cases where PCOS and FHA are especially ambiguous, alongside a detailed assessment of your adrenal hormones and various neurotransmitter metabolites. This can help us see how your body is dealing with stress (crucial for your other hormone systems).
Disclaimer: Even though I love using these tests to find the root cause of symptoms, they are not medically diagnostic tools and should not be used to diagnose or treat any medical condition. They are intended to provide additional insights into your body’s biochemistry and can help identify areas where you may benefit from personalised nutrition and lifestyle adjustments.
Conclusion
Differentiating between PCOS and FHA is essential for appropriate management and improved patient outcomes. The NICE CKS for secondary amenorrhoea assessment provides a valuable framework for GPs and other HCPs but may benefit from additional updates to reflect the latest evidence and best clinical practice. By understanding the nuances of each condition, healthcare providers can make more informed decisions, and patients can be better supported on their health journey. Accurate diagnosis, personalised treatment plans, and patient empowerment are key to managing these complex conditions effectively.
If you’d like information on how I can help you with the above, please get in touch and book a call with me. I’d love to support you in regaining your hormone health.
DISCLAIMER:
The policy evaluation (the research paper) shared and referenced in this blog post was completed in August 2023. The NICE CKS for secondary amenorrhoea has since been updated (since the original paper was completed). However, at the time of writing this article, it would still benefit from additional updates to reflect the latest evidence and best clinical practice. I hope that the clinical guidance continues to be improved and updated in a timely manner in line with the recommendations cited here and any more that come to light in years to come.
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Always seek the advice of your doctor or another qualified health provider with any questions you may have regarding a medical condition or eating disorder recovery. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.
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